Scuba Mask -- HydroOptix - Diver Registration

HydroOptix Consumer Registration Our privacy policy
*Indicates fields that are required.
Salutation	Mr.Mrs.MissMs.Dr.
First Name*
Middle Initial
Last Name*
Address1*
Address2
City*
State*
Zip*
Country*
Phone*
Fax
e-mail*	Please be sure your e-mail address is correct.

How I
heard about
HydroOptix

	Other
	Internet search
	Saw somebody using one!
	Friend
	HydroOptix VisTA (Vision Trained & Authorized Scuba Professional)

*Year of Birth

As we age, our close-focus ability changes, even decades before needing reading glasses or bifocals. We must know your age to give you our best advice.

*Have you had refractive eye surgery? (i.e. Lasik, PRK, Radial Keratotomy)	Yes	No
*Do you wear ANY KIND of Rx glasses, reading glasses, or contact lenses?	No, I have perfect vision Skip to comments	Sometimes I go without Rx eyewear	Always
*I am	Nearsighted lenses required to focus on distant objects
Pick one ===>	Farsighted NOT AGE RELATED need for reading glasses (presbyopia). Instead, you've needed eyeglasses since you were young
	20/20 (Nothing required for distance vision)
*I need	Astigmatism correction
*Reading correction?	Reading glasses (NOT bifocals)
(Presbyopia)	Bifocals/Progressive lenses
*Experience wearing contact lenses?	Never Worn Seldom	Current/Frequent No Longer
*Do you wear Contact lenses while diving? A prescription dive mask?	Yes Yes	No No

Comments/
Questions




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